Caregiver Applicant Form

Personal Information

* First Name

*Last Name

* Email

* Address Line 1

Address Line 2

* Country

* State/Province

* City

* Zip/Postal Code

*Gender

* Mobile Phone

* Home Phone

*Date of Birth

* SSN

Educational Background New Educational Background

School/College/University

Qualification

Attach Document

Employment History New Employment History

Please provide your latest employer information below.

Employer Name

Phone Number

Address

Country

State/Province

City

Zip/Postal Code

Served From

Served To

Position Held

Attach Document

References New Reference

Name

Phone Number

Miscellaneous Questions

Q.) Are you either an US citizen or alien authorized to work in the United States? Yes or No

Q.) Are you at least eighteen (18) of age? Yes or No

Q.) Have you ever used an aliases or different social security? Yes or No. If Yes, please list all aliases or social security numbers.

Q.) Have you ever been placed on the departments employee disqualification list for any period? Yes or No. If yes please explain.

Q.) Have you ever been named as a perpetrator of abuse/neglect or exploitation of a child, elderly person or adult by a state agency in a case where the state agency determined that the allegations against you were valid or substantiated? Yes or No. If yes, please explained.?

Q.) Have you ever plead guilty, nolo contendere or been convicted of any crime, misdemanor or felony, in this state or any other state, except minor traffic offenses? To fully answer this question, you must disclose any crime for which you received a suspended imposition of sentence whether or not you are still on probation.

Q.) Are you registered with the Family Care Safety Registry maintained by the Department of Health and Senior Services? Yes or No

Q.) Do You Smoke?

Q.) Do you have a Skilled License/ Certification? If yes list type.

Q.) Do you have any experience working with persons who have physical/cognitive disabilities? Yes or No. If Yes explain the duties.

Q.) Do you prefer working with males, females, or either

Q.) List Days and Hours of the week that your are available?

Q.) Are you currently employed? Is so may we inquire of your present employer? Yes or No

Caregiver Application Form

Personal Information

Educational Background New Educational Background

Certifications

Employment History New Employment History

Skills/ Preferences

References New Reference

Miscellaneous Questions

* Caregiver Signature